Back Pain Mystery Solved… It Was Lyme Disease

Back pain may appear mechanical even when imaging does not explain its severity
Lyme radiculitis can resemble sciatica or a pinched nerve
Nighttime pain and additional neurologic symptoms may provide important clues

Back pain is one of the most common complaints in medicine. For most people, it is caused by something mechanical—disc degeneration, muscle strain, arthritis, or a pinched nerve.

But sometimes, the cause is not structural alone.

Back pain associated with Lyme disease may mimic disc disease or muscle strain, but in some patients it reflects a broader inflammatory, neurologic, or migrating pain pattern.

Back pain can be one presentation of Lyme disease and is discussed alongside other multisystem symptoms in our Lyme disease symptoms guide, where musculoskeletal, neurologic, and autonomic patterns are explained in context.

I treated a patient whose back pain defied every conventional explanation—until Lyme disease entered the differential diagnosis.

Back pain in Lyme disease may be part of a broader pattern of chronic Lyme disease pain, where symptoms can involve nerves, joints, muscles, or inflammatory pathways and do not always follow typical mechanical patterns.

Surgery and Rehab: A Promising Start

My patient had struggled with lower back pain for years. Eventually, he underwent back surgery followed by a dedicated course of rehabilitation.

For the first time in years, he was pain-free. He returned to daily activities, spent more time with his family, and felt like he had his life back.

The Pain Returns—Worse Than Before

Several months later, the pain returned.

But this time, it was different. The pain was severe, deep, and unrelenting.

There had been no new injury. He had not lifted anything heavy. His physical therapy routine remained consistent.

Yet the pain—centered in his lower back—grew worse by the week.

He returned to his neurosurgeon. Repeat imaging showed no recurrent disc herniation, surgical complication, or structural finding that adequately explained the severity of his symptoms.

A 9-Month Search for Answers

He was referred to pain management. He tried anti-inflammatory medications, additional physical therapy, and trigger-point injections.

Nothing helped.

The pain affected every aspect of his life. Sleep became difficult. Activity worsened his symptoms. Fear of triggering pain led him to avoid movement altogether.

For nine months, every path led to another dead end.

No Tick Bite. No Rash. But Something Was Off

What made the case especially puzzling was the absence of classic Lyme disease clues.

There was:

• No known tick bite
• No erythema migrans rash
• No fever

Lyme disease was not being considered.

But over time, additional symptoms appeared:

• Fatigue
• Low mood
• Brain fog
• Growing sensitivity to heat and cold

It no longer seemed like just a spine problem.

A Broader Workup—and a Surprising Diagnosis

Because his symptoms were no longer isolated to the back, we broadened the differential diagnosis.

Testing was pursued for autoimmune disease, neurologic disorders, and chronic infections.

Lyme disease testing returned positive, including multiple IgG Western blot bands. Antibody findings cannot independently determine when an infection occurred or prove that Lyme disease explains a patient’s symptoms. In this case, however, the results were considered alongside his exposure risk, clinical history, and broader symptom pattern.

For the first time, there was a potential explanation extending beyond a structural spine disorder alone.

How Lyme Disease Can Produce Back Pain

Lyme disease is caused by the bacterium Borrelia burgdorferi.

Although Lyme disease is commonly associated with joint pain and flu-like illness, neurologic Lyme disease can involve the spinal nerve roots, producing an inflammatory condition known as radiculitis.

Radiculitis may cause:

• Burning, piercing, stabbing, or tearing pain
• Sciatica-like symptoms
• Deep back or trunk pain
• Pain radiating into an arm or leg
• Pain that changes location
• Pain that is particularly severe at night
• Weakness or sensory changes that appear after the pain begins

A 2025 European guideline describes Lyme radiculitis as segmental pain that may change location, becomes worse at night, and responds only mildly to conventional analgesics. The guideline reports that some patients subsequently develop neurologic deficits, with weakness occurring more often than sensory loss.⁵

These European observations are clinically informative, although differences in Borrelia species and disease patterns mean that European frequency estimates should not automatically be applied to patients in the United States.

Lyme disease may also contribute to neuropathic pain that does not follow a typical mechanical pattern.

Can Lyme Radiculitis Be Mistaken for a Pinched Nerve?

Yes. Both Lyme radiculitis and a mechanically compressed nerve can produce radiating pain, numbness, tingling, weakness, or changes in reflexes.

A pinched nerve usually results from physical compression associated with a herniated disc, spinal stenosis, arthritis, or another structural problem. Lyme radiculitis involves inflammation affecting a nerve root.

Clues that may prompt consideration of Lyme radiculitis include:

• Pain that is unusually severe or disproportionate to imaging findings
• Burning, stabbing, or tearing pain that is worse at night
• Pain that changes location or involves more than one nerve distribution
• Limited improvement with conventional pain treatment
• New weakness developing after the pain begins
• Associated headache, stiff neck, facial weakness, or other neurologic findings
• Potential tick exposure in an endemic area

None of these findings is specific to Lyme disease. Mechanical spine disease, shingles, diabetes, autoimmune disorders, vitamin deficiencies, tumors, and other infectious or neurologic conditions may produce overlapping symptoms.

Lyme disease and degenerative spine disease can also coexist. An abnormal MRI does not necessarily prove that every symptom comes from the structural finding, just as an unrevealing MRI does not establish Lyme disease as the cause.

What Can an MRI Show?

MRI is useful for identifying disc herniation, spinal stenosis, tumors, infection, and other structural or inflammatory abnormalities. It is also important for excluding conditions that may require urgent intervention.

However, routine imaging does not always identify the source of neuropathic or radicular pain. Several published cases describe patients whose severe back pain initially resembled disc disease, sciatica, or another spinal disorder. In some cases, no adequate mechanical explanation was identified, and Lyme neuroborreliosis was considered only after additional symptoms or testing emerged.^1-4

Imaging therefore needs to be interpreted alongside the neurologic examination, symptom pattern, exposure history, laboratory findings, and alternative diagnoses.

Treatment—and Recovery

Once diagnosed, the patient began treatment tailored to his clinical presentation.

Within several weeks, the severe burning back pain gradually began to improve.

Over time, the fatigue, cognitive symptoms, and sensory sensitivity also started to fade.

Within a few months, he was functioning well again and returning to normal daily activities.

This individual outcome does not establish that Lyme disease explains unexplained back pain in other patients. It illustrates why clinicians sometimes need to reconsider the diagnosis when the course of an illness no longer fits the original mechanical explanation.

When to Consider Lyme Disease in a Patient With Back Pain

Lyme disease may deserve consideration when back pain:

• Is not adequately explained by imaging or examination findings
• Fails to improve with appropriate conventional treatment
• Includes burning, radiating, or neuropathic features
• Is unusually severe or worse at night
• Changes location or is followed by weakness
• Occurs with fatigue, brain fog, facial weakness, headache, or other neurologic symptoms
• Develops after potential tick exposure in an endemic area

Severe or progressive weakness, loss of bladder or bowel control, saddle numbness, fever, major trauma, or rapidly worsening pain requires urgent medical evaluation. These findings may indicate spinal cord or nerve compression, infection, or another serious condition.

Frequently Asked Questions

Can Lyme disease cause back pain?

Yes. Neurologic Lyme disease may involve the spinal nerve roots and produce radicular or neuropathic pain resembling sciatica or disc-related back pain. Back pain remains common and has many other possible causes.

Can Lyme radiculitis feel like a pinched nerve?

Yes. Both conditions may cause radiating pain, numbness, tingling, weakness, or reflex changes. Lyme radiculitis may be considered when pain is unusually severe, worse at night, changes location, or occurs with other neurologic symptoms or potential tick exposure.

Can an MRI diagnose Lyme radiculitis?

No. MRI can identify or exclude important structural causes of radicular pain, but it does not independently diagnose Lyme radiculitis. Diagnosis requires interpretation of the clinical presentation, examination, exposure history, laboratory findings, and competing diagnoses.

Does a normal MRI mean back pain is caused by Lyme disease?

No. An unrevealing MRI does not establish Lyme disease as the cause. Neuropathic pain can occur for many reasons, and Lyme disease should be considered only within an appropriate clinical context.

Clinical Takeaway

Back pain is usually mechanical, but Lyme neuroborreliosis may occasionally produce radicular pain that resembles sciatica, disc disease, or a pinched nerve.

Nighttime pain, changing pain location, limited response to conventional treatment, later weakness, and accompanying neurologic symptoms may justify broadening the differential diagnosis. These features are not specific to Lyme disease and must be interpreted alongside imaging, examination findings, exposure history, testing, and other possible causes.

When the severity and pattern of back pain are not adequately explained by structural findings, clinicians may need to look beyond the spine alone.

Related Articles

Podcast: Severe Neuropathic Pain Due to Lyme Disease
Neck Pain in a Child With Lyme Disease Due to Radiculoneuritis
Lyme Disease Causes Inflammation of the Spinal Cord

References

1. Chanier S, Lauxerois M, Rieu V. Back pain without radiculitis as an initial manifestation of Lyme disease: two cases. Presse Med. 2007;36(1 Pt 1):61-63.
2. Salaami O, Manning DM. Woman with lower back pain, SIADH and a twist of Lyme. BMJ Case Rep. 2018;2018:bcr2018225801.
3. Weitzel T, Perez I, Porte L. Lyme borreliosis presenting as severe back pain after Shinrin-Yoku (forest bathing) in southern Germany. J Travel Med. 2022;29(2):taab030.
4. McKenzie I, Tsarfati EM. Lyme radiculopathy in a septuagenarian. BMJ Case Rep. 2023;16(6):e251982.
5. Rauer S, Kastenbauer S, Dersch R, et al. Guidelines for diagnosis and treatment in neurology—Lyme neuroborreliosis. Ger Med Sci. 2025;23:Doc13.

This article is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment.

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Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.

Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention